Bone Metabolism Drugs
PDL Reference Documents
PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | New Drug Evaluation |
|---|---|---|---|---|---|
| alendronate sodium | ALENDRONATE SODIUM | TABLET | Y | ||
| alendronate sodium | FOSAMAX | TABLET | Y | ||
| ibandronate sodium | IBANDRONATE SODIUM | TABLET | Y | ||
| risedronate sodium | ACTONEL | TABLET | Y | ||
| risedronate sodium | RISEDRONATE SODIUM | TABLET | Y | ||
| abaloparatide | TYMLOS | PEN INJCTR | N | PA Document | |
| alendronate sodium | ALENDRONATE SODIUM | SOLUTION | N | PA Document | |
| alendronate sodium | BINOSTO | TABLET EFF | N | PA Document | |
| alendronate sodium/vitamin D3 | FOSAMAX PLUS D | TABLET | N | PA Document | |
| calcitonin,salmon,synthetic | CALCITONIN-SALMON | SPRAY/PUMP | N | PA Document | |
| calcitonin,salmon,synthetic | MIACALCIN | VIAL | N | PA Document | |
| calcitonin,salmon,synthetic | CALCITONIN-SALMON | VIAL | N | PA Document | |
| denosumab | PROLIA | SYRINGE | N | PA Document | |
| ibandronate sodium | IBANDRONATE SODIUM | SYRINGE | N | PA Document | |
| raloxifene HCl | RALOXIFENE HCL | TABLET | N | PA Document | |
| raloxifene HCl | EVISTA | TABLET | N | PA Document | |
| risedronate sodium | ATELVIA | TABLET DR | N | PA Document | |
| risedronate sodium | RISEDRONATE SODIUM DR | TABLET DR | N | PA Document | |
| romosozumab-aqqg | EVENITY | SYRINGE | N | PA Document | |
| romosozumab-aqqg | EVENITY (2 SYRINGES) | SYRINGE | N | PA Document | |
| teriparatide | FORTEO | PEN INJCTR | N | PA Document | |
| teriparatide | TERIPARATIDE | PEN INJCTR | N | PA Document | |
| denosumab | XGEVA | VIAL | |||
| ibandronate sodium | IBANDRONATE SODIUM | VIAL | |||
| pamidronate disodium | PAMIDRONATE DISODIUM | VIAL | |||
| zoledronic ac/mannitol/0.9NaCl | ZOLEDRONIC ACID | PIGGYBACK | |||
| zoledronic acid | ZOLEDRONIC ACID | VIAL | |||
| zoledronic acid/mannitol-water | RECLAST | PGGYBK BTL | |||
| zoledronic acid/mannitol-water | ZOLEDRONIC ACID | PGGYBK BTL | |||
| zoledronic acid/mannitol-water | ZOLEDRONIC ACID | PIGGYBACK |